In response to PA-09-164, "NIH Exploratory/Developmental Research Grant Program (R21)", a randomized pilot study is proposed to test the efficacy of SWIFT: Social Work Intervention Focused on Transitions among at-risk older adults following hospital discharge to home. Transitions between care settings or different levels of care create elevated risk for poor outcomes and for readmission among older adults leaving the hospital for home largely due to fragmented care and poor communication. While few studies exist that test methods to improve transitions, those available are largely medically focused, using a nurse or advanced practice nurse in their approach. Although evidence exists to support the effectiveness of these models, few have been replicated and none have been integrated into standard health care practice. This may be attributed, in part, to the availability of the needed staff, the lack of existing structures to support these roles, and the costs of implementing these interventions. The proposed study will build on existing efforts to improve transitions by employing professional social workers to improve linkages with community services, reduce care duplication, and address both medical and psychosocial patient needs during and after the transition process. A randomized controlled trial will be used to test the social work transitions model designed to improve care provided to frail older adults discharged from the hospital to community living. Eligible patients consenting to participate will be randomly assigned to either the social work transitions model intervention or a modestly enhanced model of usual care. Those randomized to the intervention arm will receive six sessions from the social worker, at least two provided in the home. The social work intervention is designed to overcome common problems following hospital discharge including medication review, discussion and planning around discharge instruction, assistance in scheduling follow up appointments, assessments of psychosocial and other support service needs and provision of linkages to address those needs. Outcomes will be measured at three and six months following arrival at home, with an interim measure of satisfaction at 10 days following arrival at home, to answer the following hypotheses: 1. Patients receiving the SWIFT intervention will have fewer hospital readmissions at three and six months following the initial hospital discharge as compared to those receiving usual care. 2. Patients receiving SWIFT intervention, if readmitted, will report longer time periods between hospital discharge and readmission to the hospital at three and six months following the index hospital admission as compared to those receiving usual care. 3. Patients receiving SWIFT intervention will report higher comprehension of post-discharge recommendations than those receiving the usual care. PUBLIC HEALTH RELEVANCE: This study aims to test a Social Work Intervention focused on Transitions (SWIFT) among at-risk older adults following hospital discharge to home. There is considerable evidence of elevated risk for error, complications, and poor outcomes during the transitional care process. Medical social workers are uniquely suited to bridge the gap between the medical needs of the patients and their psychological and social needs while transitioning from the hospital to home.